Medicare / Medicaid Claims Fraud Investigator

Location: Washington, DC
ANALYTICA is seeking a Medicare / Medicaid Claims Fraud Investigator to perform in-depth evaluation and analysis of potential fraud cases and requests for information using claims information and other sources of data. The PI Analyst will be responsible for supporting the development of complex cases that involve high dollar amounts, sensitive issues, or that otherwise meet criteria for referral to law enforcement, recoupment of overpayment, and/or administrative action based on reactive and proactive data analysis.

  • Conducts independent investigations resulting from the discovery of situations that are suspected to involve fraud, waste, or abuse.  Utilizes data analysis techniques to detect aberrancies in Medicare and Medicaid claims data, and proactively seeks out and develops leads received from a variety of sources (e.g., CMS, OIG, fraud alerts).
  • Completes written referrals to law enforcement and takes steps to initiate recoupment of overpaid monies.
  • Refer suspected instances of apparent unethical or improper practices or unprofessional conduct (e.g., quality of care issues) to the appropriate entity.  For Medicaid-related issues, shall coordinate with the State Program Integrity Unit and any other entities at state request within the state responsible for ethical, professional or quality of care issues. For Medicare-related issues, the UPIC shall coordinate with the Quality Improvement Organization (QIO).  For issues involving both programs, the UPIC shall coordinate across these entities.
  • Responds to requests for information from law enforcement.  Maintains cases that were referred to law enforcement. 
  • Reviews information contained in standard claims processing system files (e.g., claims history, provider files) to determine provider billing patterns and to detect potential fraudulent or abusive billing practices or vulnerabilities in Medicare policies and initiates appropriate action.
  • Makes potential fraud determinations by utilizing a variety of sources such as the UPIC’s internal guidelines, Medicare and Medicaid provider manuals, Medicare and Medicaid regulations, and the Social Security Act.
  • Develops and prepares potential Fraud Alerts and Program Vulnerabilities for submission to CMS; shares information on current fraud investigations with other Medicare contractors, law enforcement, and other applicable stakeholders.
  • Reviews and responds to requests for information from Medicare and Medicaid stakeholders as assigned; pursues applicable administrative actions during investigation/case development (e.g., payment suspensions, civil monetary penalties, requests for exclusion, etc.)
  • Participates in onsite audits in conjunction with investigation development.  Provides support of cases at hearing/appeal and ALJ level.  Maintains chain of custody on all documents and follows all confidentiality and security guidelines.
  • Compiles and maintains various documentation and other reporting requirements.  Performs other duties as assigned by PI Management that contribute to UPIC goals and objectives.Job Qualifications:
  •  At a minimum, a high school diploma, with preference given to those candidates who have successfully completed college or technical degree programs related to the position (e.g., criminal justice, statistics, data analysis, etc.)
  • Preference will also be given to those individuals that have attained the Certified Fraud Examiners (CFE) designation.
  • Excellent oral, written and verbal skills.
  • Ability to work independently with minimal supervision.
  • Knowledge of statistics, data analysis techniques, and PC skills are preferred.
  • At least 1 year of experience in program integrity investigation/detection or a related field that demonstrates expertise in reviewing, analyzing/developing information, and making appropriate decisions.
  • Preference is given to those candidates with experience in fraud detection and investigation within the Medicare and/or Medicaid program.

About ANALYTICA: Analytica is a leading consulting and information technology solutions provider to public sector organizations supporting health, civilian, and national security missions. Founded in 2009 and headquartered in Washington D.C., the company is an established SBA certified HUBZone and 8(a) small business that has been recognized by Inc. Magazine each of the past three years as one of the 250 fastest-growing companies in the U.S.  Analytica specializes in providing software and systems engineering, information management, analytics & visualization, agile project management, and management consulting services. The company is appraised by the Software Engineering Institute (SEI) at CMMI® Maturity Level 3 and is an ISO 9001:2008 certified provider.

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